Pre-operative high resolution computed

tomography scans for cholesteatoma:

Has anything changed?

Jia Hui Ng, MBBS

a
, Edward Zhiyong Zhang, MBBS, MRCS
a
,
Sue Rene Soon, MBBS, MRCS, MMed(ORL), FAMS(ORL)
a
,
Vanessa Yee Jueen Tan, MBBS, MRCS
a
, Tiong Yong Tan, MBBS, FRCR, FAMS
b
,
Paul Kan Hwei Mok, MBBS, FRCS, FAMS
c
,
Heng Wai Yuen, MBBS, MRCS, Mmed(ORL), DOHNS
a, c,

a
Department of Otolaryngology-Head & Neck Surgery, Changi General Hospital
b
Department of Radiology, Changi General Hospital
c
Department of Otolaryngology-Head & Neck Surgery, Khoo Teck Puat Hospital
A R T I C L E I N F O A B S T R A C T
Article history:
Received 16 February 2014
Objective: CT temporal bone scans are often performed to aid in surgical planning and
management of cholesteatomas. With improvements in the resolution of CT scans today, it
is now possible to obtain more information from these scans than before. The aim of this
study is to compare findings on high resolution CT (HRCT) temporal bone scans to intra-
operative findings, so as to determine how well various middle ear structures are assessed
by HRCT scanning.
Study design: Retrospective study.
Setting: Otology clinic of a tertiary otolaryngology centre.
Subjects and methods: 32 mastoidectomies performed by a single otologist for clinically
confirmed cholesteatoma were included. Correlation of CT and intra-operative findings on
the status of structures including the ossicles, semicircular canals, facial canal and tegmen
was analysed using kappa and AC
1
statistics.
Results: In all patients, a soft tissue mass with bony erosion in keeping witha cholesteatoma
was seen on CT. Radiosurgical agreement was excellent for the presence of semicircular
canal erosion (k = 0.89, AC
1
= 0.96), facial canal dehiscence (k = 0.74, AC
1
= 0.76), tegmen
erosion (k = 0.76, AC
1
= 0.92) and malleus erosion (k = 0.76, AC
1
= 0.85). It was good for incus
erosion (k = 0.71, AC
1
= 0.92) and stapes erosion (k = 0.63, AC
1
= 0.73).
Conclusion: There was good to excellent radiosurgical agreement in the assessment of the
status of various middle ear structures. Improvement in radiosurgical agreement from
existing studies in the literature was noted. This was especially true for features such as
facial canal dehiscence. With technological advancements, CT temporal bone scans appear
even more valuable for evaluation of patients prior to cholesteatoma surgery.
2014 Elsevier Inc. All rights reserved.
A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 5 ( 2 0 1 4 ) 5 0 8 5 1 3

There are no conflicts of interests or financial disclosures.

Corresponding author at: Department of Otolaryngology Head & Neck Surgery, Changi General Hospital, 2 Simei Street 3, Singapore
529889. Fax: +65 6260 1712.
E-mail address: heng_wai_yuen@cgh.com.sg (H.W. Yuen).
http://dx.doi.org/10.1016/j.amjoto.2014.02.015
0196-0709/ 2014 Elsevier Inc. All rights reserved.
Avai l abl e onl i ne at www. sci encedi r ect . com
ScienceDirect
www. el sevi er . com/ l ocat e/ amj ot o
1. Introduction
The resolution of computed tomography (CT) scans of the
temporal bone has improved over the last decade, making it
possible for radiologists and clinicians to obtain more details
from imaging. A high-resolution computed tomography
(HRCT) of the temporal bone is an important preoperative
investigation for cholesteatoma surgery. Prior knowledge
about temporal bone anatomy and disease extent can help
surgeons plan their surgical approach. Additionally, HRCT
scans can also highlight the presence of potentially dangerous
problems such as facial canal dehiscence, erosion of tegmen
withdural exposure, or semicircular canal erosion, thus aiding
surgeons in avoiding surgical complications [1].
However, while the HRCT has a valuable role in evaluating
patients with cholesteatoma prior to mastoidectomy, it is also
important to be cognizant of any limitations and pitfalls.
Some studies have highlighted that CT scans may mislead-
ingly suggest the presence of lateral semicircular canal
fistulization, tegmen tympani erosion, and facial nerve
involvement as these structures have thin bony covering
that may be subject to volume averaging with adjacent soft
tissues [24]. This may in turn affect the surgical management
of suppurative ear disease [2]. Another study found that pre-
operative CT scans contributed little to surgical management
and is of questionable value [5]. Most prior studies were
performed using HRCT scanning with 1.01.5 mm thick cuts
[1,2,6,7]. Also, some studies done included all types of chronic
suppurative ear disease [13,8], which may cause study results
to be difficult to interpret as cholesteatomas, middle ear
mucosal disease, and granulation are very different
disease entities.
In our institution, temporal bone HRCT scans are per-
formed with finer 0.5 mmcuts, which minimize problems due
to volume averaging. The question then arises if clinicians can
now obtain more accurate information pre-operatively than
previously described.
The aim of this study is to correlate findings on 0.5 mm
fine-cut HRCT temporal bone scans to intra-operative findings
of patients with cholesteatoma, so as to determine the degree
of radio-surgical agreement.
2. Methodology
This is a retrospective study of 31 consecutive patients (32
ears) who have undergone mastoidectomy for acquired
cholesteatoma from December 2009 to June 2012. The
mastoidectomies were performed by a single otologist at 2
tertiary otolaryngology centres.
All HRCT scans were performed during the period of March
2009 to March 2012. The CT scanner used to image the
temporal bone was the Toshiba Aquilon One, where a volume
scan without IV contrast was performed with the patient in
supine position. Scan parameters applied were: A small field
of view usually about 220 mm or lesser, 60 mm scan range,
0.5 s rotation time, FC 81 filter, 120 kV, 180 mA exposure, and
volume data are acquired at 0.5 mm slice thickness (super
resolution)/0.25 scan interval, with axial and coronal images
reconstructed to 0.5/0.5 mm from the volume data acquired.
All the HRCT scans were read by the same radiologist
specialized in reading temporal bone imaging.
The pre-operative HRCT scans were reviewed retrospec-
tively with the radiologist blinded to intra-operative findings,
and assessed for the following: (a) tegmen tympani erosion,
(b) facial canal dehiscence, (c) semicircular canal erosion,
(d) ossicular erosion (malleus, incus and stapes). Surgical
findings were similarly reviewed and compared with radio-
logical findings.
Cohens Kappa and Gwets AC
1
statistic [9] were both used
to measure the amount of agreement between HRCT findings
and surgical findings. The AC
1
, introduced in 2001, has been
used by multiple studies for determining agreement [1012].
The Kappa has also been widely used in previous studies and
is included in this study to facilitate comparison. Cut off
values used in the interpretation of the Kappa and AC
1
statistic are shown in Tables 1 and 2. Additionally, sensitivity
and specificity, as well as the positive and negative predictive
value (PPV and NPV) of HRCT scanning for identifying disease
features (a) to (d) were calculated. SPSS version 20 (SPSS Inc.,
Chicago, IL) was used for statistical analysis where applicable.
This study was approved by an independent ethics commit-
tee, the centralised institutional review board.
3. Results
A total of 31 scans and 32 mastoidectomies were reviewed.
In all patients, a soft tissue mass with bony erosion in
keeping with a cholesteatoma was seen on CT. There was 1
revision mastoidectomy. All operations were completed as
planned. The main findings of this study are summarized in
Tables 3 and 4.
3.1. Tegmen tympani erosion
Tegmen tympani erosion (Fig. 1) was noted in 5 (15.6%) HRCT
scans; this was confirmed in 4 cases intra-operatively, but no
tegmen tympani erosion was found intra-operatively in 1
case. Additionally, in 1 of 27 scans negative for tegmen
tympani erosion, pre-existing dural exposure was found
Table 1 Interpretation of the Kappa value.
Kappa value Strength of agreement
k > 0.75 Excellent
0.40 < k < 0.75 Fair to good
k < 0.40 Poor
Table 2 Interpretation of the AC
1
value.
AC
1
value Strength of agreement
AC
1
> 0.8 Very strong
0.6 < AC
1
< 0.8 Moderately strong
0.3 < AC
1
< 0.5 Fair
AC
1
< 0.3 Poor
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during surgery. PPV was therefore 0.80 and NPV was 0.96.
Specificity of HRCT scan, at 0.96, is better than its sensitivity,
at 0.80. Excellent radiosurgical agreement was present with
k = 0.76 and AC
1
= 0.93.
3.2. Semicircular canal erosion
Semicircular canal erosion (Fig. 2) was noted in 6 (18.8%) HRCT
scans. 5 cases were confirmed intra-operatively and 1 scan
was falsely positive. No scan was falsely negative for
semicircular canal erosion. As such, both sensitivity and
NPV of this finding on HRCT are 1. Radiosurgical agreement
was excellent with k = 0.89 and AC
1
= 0.96.
3.3. Facial canal dehiscence
This finding (Fig. 3) was noted in 12 (37.5%) HRCT scans, of
which 1 was falsely positive. 3 cases out of 14 cases of facial
canal dehiscence confirmed intra-operatively were not de-
tected by HRCT scanning. Also, of the 11 cases of facial canal
dehiscence picked up on HRCT, 2 scans did not correctly
identify the site of dehiscence (tympanic or mastoid or both).
Sensitivity of HRCT for this finding was 0.79, while specificity
was higher at 0.94. PPV and NPV were 0.92 and 0.85
respectively. Radio-surgical agreement was excellent with
k = 0.74 and AC
1
= 0.76.
3.4. Ossicular erosion
For evaluating the state of all 3 ossicles, the sensitivity of
HRCT scans was higher than the specificity. For detecting
erosion of the malleus, PPV and NPV were similar at 0.92 and
0.88 respectively. For detection of incus erosion, the PPV at
0.96 was higher than NPV, which was 0.75. On the other hand,
NPV for detection of stapes erosion was 0.95, which is higher
than PPV of 0.64 (Fig. 4). Radiosurgical agreement was
excellent for the malleus and incus with Kappa and AC
1
values of more than 0.70, but only good for the stapes (k = 0.63,
AC
1
= 0.73).
4. Discussion
Our results suggest that HRCT scans are able to accurately
assess middle and inner ear structures. Across almost all
structures studied, radiosurgical agreement was very strong
(in accordance with the AC
1
statistic). Only in assessing the
stapes is radiosurgical agreement only moderately strong.
When the results of this study are compared to those
obtained by other similar pre-existing studies, it was notable
that while there are studies which found stronger levels of
radiosurgical agreement thanthis study inassessing one or more
middle/inner ear structures, no other study had found strong
levels of radiosurgical agreement across all structures studied.
We attribute our high degree of radiosurgical agreement
based ona fewfactors. It is the protocol inour institution to use
fine cuts of 0.5 mm to image the temporal bone, minimizing
volume averaging with adjacent soft tissue, and thus providing
better resolution. We ensured that all scans were reconstructed
in axial and coronal planes. We also utilized a baseline window
width of 4000 Hounsfield Units (HU), and window center of
700 HU, before fine adjustments were made to enhance
structures as required. Lastly, our specialized radiologist has
had vast experience in head and neck radiology, and works
closely with the Otolaryngology department.
Due to the heterogenous methods that other similar
studies done in the past used to report their results, it was
difficult to make direct comparisons between studies to draw
useful conclusions. To overcome this issue, our study used
both Kappa and AC
1
to measure agreement. Additionally, the
sensitivity, specificity, PPV, and NPV, which some studies
used, were also calculated. The use of PPV and NPV is less
appropriate in this circumstance, as they are highly affected
by the prevalence of the findings within the study population.
4.1. Tegmen tympani erosion
Knowledge of the presence of tegmen tympani erosion with
dural exposure can alert the surgeon to an important hazard.
Table 3 Relationship between HRCT and intraoperative
findings.
HRCT findings
(n = 32)
Intact Abnormal
Intraoperative
Findings (n = 32)
Tegmen Intact 26 1
Eroded 1 4
Semicircular
Canal
Intact 26 1
Eroded 0 5
Facial Canal Intact 17 1
Dehiscent 3 11
Malleus Intact 7 2
Eroded 1 22
Incus Intact 3 1
Eroded 1 27
Stapes Intact 20 4
Eroded 1 7
Table 4 Ability of HRCT scans to assess various middle/
inner ear structures.
Finding Kappa AC
1
Sensitivity Specificity PPV NPV
Tegmen
tympani
erosion
0.76 0.92 0.80 0.96 0.80 0.96
Semicircular
canal erosion
0.89 0.96 1 0.96 0.83 1
Facial canal
dehiscence
0.74 0.76 0.79 0.94 0.92 0.85
Malleus
erosion
0.76 0.85 0.96 0.78 0.92 0.88
Incus
erosion
0.71 0.92 0.96 0.75 0.96 0.75
Stapes
erosion
0.63 0.73 0.88 0.83 0.64 0.95
PPV = positive predictive value.
NPV = negative predictive value.
Bolded Kappa and AC1 values show excellent and very strong
agreement respectively.
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Such defects are best seen in the coronal plane. The excellent
level of radiosurgical agreement noted in our study
was unprecedented.
Earlier studies performed in the 1980s to 1990s were unable
to achieve both high sensitivity and high specificity in
determining the presence of tegmen tympani erosion from
CT scans. For example, Jackler et al. [3] found CT scans with
1.5 mm contiguous slices to have sensitivity of 1 but a
specificity of only 0.21. On the other hand, Mafee et al. [13]
found that sensitivity of CT scans for this finding was 0.50 and
specificity was 1. Similarly, a study by OReilly et al. [8] found
sensitivity to be 0.45, with a substantial number of false
positive results. More recent studies in 2000s also did not
show ideal radiosurgical agreement. NW Chee et al. [7] found
that the radiosurgical agreement for this finding was k = 0.65.
Vlastarakos et al. [14] found that AC
1
was 0.68. Tatlipinar et al.
[1] found that sensitivity is 0.50 and specificity is 0.93. Banerjee
et al. [2] had commendable findings with a sensitivity of 0.75
and specificity of 0.90. However, the thickness of slices used in
their CT scans was not reported and we were unable to
compare it to that done in our centre.
4.2. Semicircular canal erosion
The suspicion of the presence of semicircular canal erosion
will allowsurgeons to exercise more caution in dissecting off a
cholesteatoma sac in that region, or possibly allowing matrix
to be left over the fistula site with the sac exteriorized. All 5
defects in our study occurred on the most commonly affected
lateral semicircular canal, with none affecting the superior
semicircular canal. We found that it is useful to visualize the
lateral semicircular canal in both the axial plane along its
length, as well as along its cross-section in the coronal plane
to make the best assessment. Our study found that among all
the HRCT scan findings studied, radiosurgical agreement was
best for the presence of a semicircular canal erosion.
This is in contrast to findings in previous studies.
Tatlipinar et al. [1] (2012) found that sensitivity is 0.00 and
specificity is 0.94. Vlastarakos et al. [14] found that AC
1
= 0.68
for this finding, compared to AC
1
= 0.96 in our study. Gerami H
et al. [15] also found that radiosurgical correlation was weak
for this CT finding. In fact, older studies yielded better results
for the ability of CT scans to predict for this finding intra-
operatively. For example, OReilly et al. [8] had sensitivity of
0.75 and had a false positive rate of 3.5%, while Jackler et al. [3]
reported a specificity of 0.88.
4.3. Facial canal dehiscence
The presence of a facial canal dehiscence, whether congenital
or secondary to the cholesteatoma, puts the facial nerve at a
higher risk of injury intra-operatively. Prior knowledge of this
condition from HRCT scans would therefore be useful to the
surgeon. We find that the facial nerve is best evaluated in
its cross-section, hence the tympanic segment best seen on
coronal, while the mastoid segment in axial section. A
contiguous bony structure along the entire circumference of
the nerve is expected. We did not utilize additional sagittal
reconstructions to visualize inferior wall dehiscences as
recommended by some authors [6]. Our study nonetheless
achieved a very strong association of AC
1
value of 0.76.
In previous studies, CT scans were found not to be ideal for
evaluation of facial canal dehiscence. For example, NW Chee
et al. [7] found that the radiosurgical agreement for this
Fig. 1 Tegmen Erosion. Symbol (*) represents cholesteatoma; arrow points to tegmen defect.
Fig. 2 Semicircular Canal Fistula. Arrow points to fistula of the lateral semicircular canal.
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finding was k = 0.30, compared to k = 0.74 in our results.
Tatlipinar et al. [1] missed all 4 cases of facial canal
dehiscence. OReilly et al. [8] and Freng et al. [16] also found
that CT scans missed 44.4% and 75.0% of facial canal
dehiscence respectively.
4.4. Ossicular erosion
In our study, HRCT scans had better agreement with intra-
operative findings of the malleus and incus than for the
stapes. We find that the malleus head and incus body
were best seen on axial sections, while the handle of the
malleus and long process of the incus were better seen in
coronal sections.
The assessment of the stapes is more challenging due to
the presence of surrounding soft tissue around an already
very small structure. However, with HRCT at 0.5 mm, it was
possible to obtain a moderately strong radiosurgical agree-
ment in assessing the stapes, with an AC
1
value of 0.73.
While erosion of the stapes suprastructure may not
contribute much to the operative risk, it is important to note
that an intact stapes suprastructure tends to yield better
hearing outcomes post-operatively [17]. Pre-operative knowl-
edge of the condition of the stapes will therefore provide
information for surgeons to better counsel their patients on
hearing preservation post-operatively.
Due to difficulties with assessing the stapes, as described
above, Jackler et al. [3] and Tatlipinar et al. [1] did not attempt
to do so in their studies. Vlastarakos et al. [14] also did not
attempt to predict the state of the stapes, but reported
radiosurgical agreement for the malleusincus complex to be
AC
1
= 0.42. Surprisingly, despite using CT scans with larger
cuts than our study, NW Chee et al. [7] found that radio-
surgical agreement was better for the stapes (k = 0.94) than it
was for the malleus (k = 0.83) or incus (k = 0.62).
4.5. Limitations and strengths
One important limitation of our study is the retrospective
design. We were unable to study how HRCT temporal bone
scans affected surgical planning and the intra-operative
management of cholesteatomas in real time. However, the
strength of a retrospective design in this instance is the ability
to remove any bias in reporting surgical findings which may
arise from preoperative knowledge of CT findings.
In an ideal situation, the surgeon reporting intra-operative
findings should be blinded to the findings onthe pre-operative
HRCT scan, but this is not ethically feasible.
In addition, all patients included in this study have the
diagnosis of cholesteatoma made retrospectively following
surgery, hence these results should not be generalized to
patients with other forms of middle ear pathology.
Further, we did not study inter-observer agreement
between reporting radiologists. All radiological findings re-
ported reflect the experience of one very experienced radiol-
ogist, and may not be replicated by other radiologists.
There are some surgeons who believe a preoperative CT
scan, regardless of the resolution, is unnecessary in a patient
with cholesteatoma since the patient would require surgical
treatment in any case. With sound knowledge of anatomy and
experience, the structures in the middle ear and temporal
bone would be revealed intraoperatively. Nevertheless, the
reasons for performing an HRCT scan preoperatively for
patients with cholesteatoma are many. Firstly, the findings
Fig. 3 Facial Canal Dehiscence. Arrow points to tympanic portion of facial canal eroded by cholesteatoma.
Fig. 4 False positive for stapes erosion. Arrow points to capitulum of stapes. The crura are not visible and appear eroded.
However, the stapes was found to be intact intra-operatively.
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on scans can influence the surgical approach in different
patients. The extent of the pathology might determine the
choice of a more limited procedure (e.g., atticoantrostomy or
canal-wall-up mastoidectomy), over a more extensive opera-
tion (e.g., modified radical mastoidectomy).
Secondly, with prior knowledge of the extent of disease,
involvement of vital structures and the existence of anatomic
variants e.g., high-riding jugular bulb or low-lying dura, the
surgeon has greater confidence in full extirpation of disease
and preservation of vital structures and functions.
The benefits of a preoperative scan extend beyond the
surgery. The scans not only provide important information for
patients with regards to pre-operative counseling and illustra-
tion, but also serve as an important educational tool in helping
residents understand the anatomy of the temporal bone
particularly during surgery. It offered some medicolegal value
as well, by objective documentation of disease before surgery.
5. Conclusion
Our study showed remarkable radiosurgical agreement with
good sensitivity and specificity across all findings studied,
beyond those reported by other pre-existing studies. Our
success can be attributed to the newer CT scanners and
scanning protocols used in our institution that provide finer
slices and greater resolution, and also the presence of a
radiologist specialized in otology to report the scans. With
technological advancements, it appears that HRCT scans are
now more valuable than before in evaluating patients with
cholesteatoma pre-operatively.
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